Medical Education in Alcohol and Other Drugs: Curriculum Developement for Primary Care.

Over the past twp decades, physician education about alcohol and other drug abuse has progressed from teaching guides to full-blown curricula that focus on teaching medical students skills that are critical to the successful diagnosis and treatment of alcohol abuse. Despite these advances in teaching materials and techniques, integration of substance abuse curricula into primary care medical education has been slow at best.


Expanding the Focus
various trends in medical education, from through 1983.As an outgrowth of this slidelecturestyle didactic teaching 1 to program, Hostetler (1982) published a In 1987, the Society of Teachers of competencybased instruction and learner methodology guide for teaching about Family Medicine (STFM) published The centered and problembased learning.
alcohol and other drug abuse (table 1).
Family Medicine Curriculum Guide to Over time, curricula in the alcohol and This guide identified and described many Substance Abuse (Liepman et al. 1987), other drug abuse field have reflected a of the newer methodologies for medical which provided extensive reference and change in medical education, away from education, including interactive discus background information in a variety of the biomedical model and toward the sion, role play, and patient management areas, including pharmacology, patho biopsychosocial model of care.This has problems.It also provided curriculum been prompted by a host of factors, includ objectives for teaching.
CATHERINE E. DUBÉ, ED.D., is a clinical ing the emergence of a primary care spe assistant professor of community health cialty, a movement toward the family

Developing a Structured Format
and medical education and the curriculum practice model, a greater emphasis on development coordinator at the Center for holistic medicine, and a better understand In 1984, the Commonwealth Harvard Alcohol and Addiction Studies, Brown ing of the mindbody connection.
Alcohol Research and Teaching University, Providence, Rhode Island.This article reviews the evolution of al (CHART) program (Barnes et al. 1984) cohol and other drug abuse medical educa published an important curriculum that DAVID C. LEWIS, M. D., is a professor of tion during the last two decades and presents included detailed teaching outlines and medicine and community health, Donald G. current and future trends in learning.
an annotated bibliography.The teaching Millar Professor of Alcohol and Addiction material was content oriented, used a Studies, and director of the Center for physiology, detoxification, prevention, and substance abuse in the family.Learning objectives were listed for each of 10 teaching sessions.Teaching "hints" also were provided, including references for support material and ideas about laboratory experiments, films, and case presentations.

BiomedicalBased Models
These models focus on the physical and medical characteristics of a disorder.
In 1981 and 1982, Project CORK (named for the developers), out of Dartmouth College, developed seven instructional units in a series called "The Biomedical Aspects of Alcohol Use."The units contained more than 40 slides each, with accompanying text, and addressed topics such as pharma cology, alcohol and the liver, and alcohol and pregnancy.Three more units were published in 1989, featuring medical complications, abuse and dependence, and Native American use.A new unit, only on cocaine, is sched uled for release this year (VanWart personal communication, March 1994).

BiopsychosocialBased Models
In contrast to biomedical models of dis ease, biopsychosocial models take into consideration the psychological aspects of a disorder as well as social settings, such as the patient's family, living arrange ments, and resources.
LearnerCentered Models.In the early 1980's, the Society of General Internal Medicine's task force on medical inter viewing (now the American Academy on Physician and Patient) began offering an innovative faculty development course that used a learnercentered model.This model included role play, small group process, personal awareness, and applica tion/feedback techniques.The work of the task force reflected a movement in medicine away from the biomedical model of illness and medical care toward a more integrated biopsychosocial model, which was particularly applicable to teaching in the alcohol and other drug abuse arena.The course also advanced a skillbased approach to teaching and learning medical interviewing based on the work of Lipkin and colleagues (1985).
CompetencyBased Models.Originally described by Davies (1973) and later by Mager (1988), competencybased instruc tion can be defined as teaching and learn ing designed specifically to produce skills and behaviors critical to the competent practice of medicine.Only key content related to competencies is included and is integrated with the attitudes and skills that build competency, rather than taught in isolation.
The Association for Medical Education and Research in Substance Abuse held a consensus conference in November 1985, known as the Annenberg Consensus Conference, to identify minimal compe tencies for physicians in the area of alco hol and other drug abuse.Competencies were identified based on clinical skills and behaviors that represented minimal qualifications for practicing physicians.Results of this seminal work formed the foundation for curriculum development for years to follow (Lewis and Niven 1985;Lewis 1990).

Putting Programs Into Practice
In 1986, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) jointly sponsored the Curriculum Models Program, which funded nine curriculum development projects in seven medical schools and one STFM project.
The objectives of this initiative were to move from the conceptual to the practical by (1) providing methods of integrating alcohol and other drug abuse education into primary care education, (2) employ ing new approaches to faculty develop ment for alcohol and other drug abuse teaching, and (3) developing and pilot testing new curriculum materials.SpecialtySpecific Curricula.Some cur ricula were developed in terms of a spe cialty, such as a pediatric and an internal medicine curriculum project, both at the Johns Hopkins University, and a family medicine curriculum project at STFM.

A Closer Look at ADEPT and SAEFP
One of the integrated curriculum models, Brown University's Project ADEPT, was the first model to address skills training in screening, assessment, and referral of alcohol and other drug problems appropri ate to all primary care specialties.Teach ing tools included videos, outlines, visuals for overheads or slides, handouts, case studies, and clinical application exercises.
A total of five volumes of Project ADEPT curriculum materials were pub lished from 1989 to 1994 (Dubé et al. 1989a(Dubé et al. ,b, 1990;;Dubé and Lewis 1994a,b) SAEFP conducted 10 5day faculty development workshops at various loca tions around the United States during a 4month period in 1990.These workshops were designed to reach physician faculty in every federally funded family medicine residency program in the country, en hance their clinical and teaching skills, and offer them a set of teaching tools that would help them provide structured di dactic teaching sessions to their residents.
Teaching tools for SAEFP curriculum included goals, objectives, teaching strat egies, lecture notes, summary tables, detailed background information, and visuals for slides or overheads.

Curriculum Evaluation
The vast majority of curricula have been evaluated through face validity (i.e.,  (1982,1989,1994) • The Liver with commentary and slidelecture format.
• Hematologic Complications supporting booklets.expert and peer review) and pilottesting techniques.Research on the effectiveness of specific curriculum packages is rare, and changes in teaching techniques often are based on faculty preference.Addition ally, few dissemination studies have been conducted to determine the effects any one curriculum package may have had on teaching in the field of alcohol and other drug abuse.However, evidence of suc cessful dissemination and acceptability of curriculum materials can be gleaned from distribution statistics.
For example, more than 1,000 vol umes of Project ADEPT curriculum materials have been disseminated nation ally and internationally during the past 5 years, with volumes IV and V newly released in July 1994.Further evidence of the acceptability of these materials comes from more than 20 requests on file to reprint or reproduce various aspects of Project ADEPT in coursebooks; texts; manuals; curricula; and technical bulletins for doctors, nurses, physicians assistants, and other primary care providers.Reprint ing or reproducing of materials for typical

Measuring Change
Despite significant contributions to cur ricula in the alcohol and other drug field during the past 10 years, measurable changes in medical education continue to be slow.
In 1991, the Physician Consortium on Substance Abuse Education published a policy report stating that "substance abuse education and training for all levels of medical education is markedly deficient" (Lewis and Faggett 1991, p. 1).
The report recommended that medical education programs focus on altering physicians' actual practice behavior rather than teaching general knowledge about substance abuse.Specific recommenda tions stressed the importance of faculty development, communitybased training, and multidisciplinary approaches.
In a national curriculum survey, Flem ing and colleagues (1994) found that the mean number of teaching units reported in a sample of 126 U.S. medical schools doubled-increasing from 3.5 units in 1986 to 7.4 units in 1992.However, only eight schools reported required (as op posed to elective) course work in the alco hol and other drug abuse area.

CompetencyBased Curriculum
During the past 8 years, medical curricula in many settings have been evolving to ward a competencybased model.Because of vast amounts of medical information and limited teaching time, medical educa tors have been forced to be more efficient, more directed, and more focused.In addition, competencybased approaches allow for greater efficiencies in teaching.
The process of developing competency based instruction begins with a job analysis and expert review of practice behaviors considered to be important to the accom plishment of desirable job tasks.Curricu lum designers must prioritize and define these behaviors and detail the knowledge, skills, and attitudes needed to perform each behavior (for a detailed description of the design process, see the box, p. 151).
Designing a competencybased cur riculum is time consuming, but the result is a roadmap with wellidentified priority areas, such as the important skills of detection and diagnosis of alcohol and other drug problems.A wide range of related areas, such as case discussion points and clinical application exercises, are included should there be additional teaching time.The MD 2000 curriculum project at Brown University and all Project ADEPT programs rely on a similar competencybased design.The strength of this approach is its systematic and analytical process, which yields

Many medical schools have been moving toward a problem based curriculum that emphasizes
case studies and research over content.
practical and useful teaching materials.This is particularly important in the field of alcohol and other drugs because teach ers rarely have sufficient time in the medical curriculum to teach the important clinical skills and behaviors in this field.The one drawback is the time and re source drain that occurs during the front end analysis (i.e., audience analysis, job analysis, and behavioral outcome analy sis) and development phases.Further more, the focus on clinical practice skills and behaviors calls for teaching methods that depart from traditional didactic for mats and often requires additional faculty training and development.

ProblemBased Learning
Many medical schools2 have been moving toward a problembased curriculum that emphasizes case studies and research over content.This move has been prompted by a desire to be more learner centered and to impart lifelong learning skills.
Compared with traditional teaching approaches, problembased teaching re quires significantly different instructional aids and tools.Instead of a syllabus, stu dents in a problembased environment require case materials.Teachers need background information and resources that allow them to provide guidance to students in their quest for information.Classes, at the least, need group facilitation guidelines, clear objectives and goals for problem based work, clear guidelines for evaluation, and an organized series of intriguing cases that also stimulate important teaching activities (including discussion, research, presentations, and further inquisition).
Problembased learning offers students the opportunity not only to learn about a topic but also to research the topic and evaluate, integrate, and present their find ings.Students exposed to problembased learning exhibit significant enthusiasm for their work because they present their own findings and they teach and learn from each other.A wide variety of topics typi cally are presented after case research.These topics often extend beyond what a typical lecturer might include.
The drawback of problembased learn ing is the time, faculty, and resource requirements.The studentfaculty ratio for a traditional problembased group may be as small as 6 to 1. Faculty also need training in this technique to make it work.Without adequate training, faculty may regress to didactic, teacherdirected, contentoriented models.Also, case dis cussion prior to student research takes as long as one lecture on a given topic.Furthermore, debriefing sessions, in which all students have an opportunity for presentation and discussion of findings, can easily take the time of two didactic teaching sessions on the same topic.
The problembased format is well suited to teaching about alcohol and other drug problems.Because these problems include biopsychosocial, spiritual, and political elements, any case will be rich with re search possibilities.However, because this method requires a significant commitment of time by faculty members, it may be difficult to implement this ideal approach.

CommunityBased Teaching
Medical schools, governmentfunding agencies, and policy leaders in health care reform currently are promoting community based medical education.This shift in focus from a universitybased and hospital based setting to a communitybased one is a result of the need to emphasize primary care in medical education and the need to broaden medical student experience.
Communitybased medical education provides training in a variety of settings with a variety of patients and can offer a training experience that is closer to prac tice in the "real world" than training pro vided only in an academic medical center.However, much like problembased teach ing, it is resource intensive.
Because training increasingly will occur in community settings not currently affiliated with an academic medical cen ter, programs will have to train a new set of faculty and preceptors in clinical supervision and teaching techniques.Communitybased faculty will need mate rials that help structure the fieldtraining experience and provide students with appropriate learning activities and op portunities for research, reflection, and feedback.A curriculum package for communitybased teaching would provide timeefficient tools and methods for supervision, precepting, and consultation with students as well as means for satis fying educational standards for the ex perience.Without such an approach to communitybased teaching, the field will move back to the old apprenticeship mod el, which is an inefficient approach to physician training.Thus, tools for com munitybased learning will help standard ize education, but they also will provide criteria for the quality of teaching and learning as well as provide focus and meaning to educational experiences.
Communitybased medical education has great appeal to medical educators in the field of alcohol and other drug abuse.It provides a unique opportunity to recruit students into the treatment centers, to allow them the opportunity to learn about the treatment and recovery process, and to give them the chance to develop positive relationships with addicted and recovering patients in a medical environment.The field could benefit from a community placement curriculum package that pro vides a structure and framework for such an experience.

DEVELOPING A COMPETENCYBASED CURRICULUM FOR ALCOHOL AND OTHER DRUG ABUSE
The first step is to identify and examine physician practice behaviors important to the care-prevention, diagnosis, assessment, treatment, and ongoing care-of patients with alcohol and other drug problems.
These behaviors might include such items as: • Taking an alcohol and other drug use history • Using diagnostic criteria to assess the severity of an alcohol or other drug use problem • Developing treatment plans for patients with alcohol and other drug problems • Referring a patient to treatment • Following up with patients during and after treatment.
Expert practitioners and teachers can help develop an exhaustive list of practice behaviors and then prioritize the list.To help, they can use the following scale: Absolutely essential: would be malpractice to leave out. 2 Very important: should include if at all possible.3 Can be left out if teaching time runs out.
Each of the top or second priority items on the list is further detailed so that an extensive list of component parts for each behavior is developed.Component parts always include knowledge, skills, and attitudes.For example, component parts of the item "taking an alcohol and other drug use history" mentioned above might include: Developers can then examine the highest priority behaviors in detail.To examine fully these behaviors, they must define the role of the physician and answer the question, "What would a competent physician do to accomplish this task?"Answers to this question can be obtained from concerned and enlightened teach ers in the field and by interviewing and observing an "expert" performing the skill (e.g., counseling adolescents about alcohol behaviors).The practice behavior can then be documented and broken down into its component parts so it can be taught and learned.Component parts might include such activities as: Each of these components can then be further defined for review by experts, and additional knowledge and attitudes related to these more detailed behaviors can be identified to be sure that the task can be fully, adequately, and systemati cally taught.

FUTURE TRENDS
Finding the appropriate methods and content necessary to train competent practicing physicians depends on the definition of their appropriate roles and responsibilities.The role of the physician is not stagnant but dynamic and affected by many factors, including influences on the field of medicine, market forces and consumer demand, changing national culture and climate, advances in science and practice, and changes in reimburse ment systems and national policy.Cur rently, the most significant factor influencing the future of the physician's role is impending health care reform.

HEALTH CARE REFORM
Health care reform will be a major impetus to encourage physicians to diagnose and treat alcohol and other drug abuse prob lems early, before costly accidents and acute and chronic medical illnesses super vene.It is now anticipated that some de gree of alcohol and other drug abuse treatment will be included in the basic core benefit.Preventive clinical services also will receive more support as will increased training for primary care physicians-the socalled gatekeepers of the new system.Furthermore, managed care will force explicit diagnoses and patient matching to acceptable treatment modalities.Spurred on by the health care reform debate, the American Medical Associa tion (AMA), through the urging of their House of Delegates at their New Orleans meeting in December 1993, passed the following recommendations: • That the AMA encourage all physi cians, particularly those in primary care fields, to undertake education in treating alcohol and other drug abuse.
• That the AMA direct its representatives to appropriate residency review com mittees (RRC's) to ask the committees on which they serve to consider requir ing instruction in the recognizing and managing of alcohol and other drug abuse.Those RRC's that already re quire such instruction should consider greater emphasis for this subject.
• That the AMA encourage treatment of alcohol and other drug abuse as a sub ject for continuing medical education.
• That the AMA affirm that many physi cians in fields other than psychiatry have graduate education and experience appropriate for the treatment of alcohol and other drug abuse, utilization review, and other evaluation of such treatment, and should be entitled to compensation for performing those services.

Incentives for Substance Abuse
Training.Assuming that health care reform results in a capitated health care system (i.e., one that requires physicians to charge a standard fee up front for each patient as opposed to a feeforservice system), it will be in the interest of both purchasers and providers of service to address alcohol and other drug problems routinely because untreated alcohol and other drug abuse is so disabling and costly.The development of value, quali ty, and cost consciousness would drive the system to provide more routine and effective substance abuse services.These incentives, however, would make the shortfall in substance abuse training of physicians even more apparent and the need for new training incentives and standards a priority.
The danger is that the system may change so rapidly under health care re form that physicians will not be ready to participate in that system.

Faculty Training
Trained faculty to teach the skills related to alcohol and other drug use problems in medical schools and other health care professions continue to be needed.With the emergence of new nontraditional contexts and formats for teaching in both academic and communitybased settings, greater emphasis should be put on faculty development.
The faculty development program grants, initially administered by NIAAA and NIDA and now administered by the Center for Substance Abuse Prevention, in part address a lack of faculty with basic skills.The grants aim to develop a cadre of skilled faculty with professional identi fication in the field of alcohol and other drug abuse in each participating institu tion.However, with this program winding down, the number of core faculty capable of teaching basic skills at many medical schools remains low.

CONCLUSION
Our most valued resources in academic medicine are hardworking, dedicated faculty, including researchers, clinicians, and educators.Providing these teachers with the means, methods, and tools neces sary for excellence is where future cur ricular design and development and continued faculty development programs can help.Continued attention to curricular development and faculty development in alcohol and other drug abuse can help maintain the gains made in the field over the past two decades and help continue to promote essential alcohol and other drug abuse teaching in U.S. medical schools.■ Knowledge • Diagnostic criteria for abuse and dependence • Terminology: drugs of abuse • Natural history of alcohol and other drug abuse problems Skills • Asking about past use patterns • Applying the diagnostic criteria • Asking about previous attempts to quit • Asking about previous treatment experiences • Assessing the patient's history Attitudes • Unconditional positive regard for the patient • Caring, helpfulness, and empathy for the patient's experience(s).

•
Bringing up the topic of drinking behaviors among peers and family • Assessing the patient's current drinking behaviors • Determining context and setting of current drinking behaviors • Developing a common understanding of the risks of drinking • Identifying motivational factors for changing risky behaviors • Linking benefits of changing drinking behaviors to motivational factors • Negotiating change • Following up.

Table 1
Summary of Alcohol and Other Drug Abuse Curricula for Physicians NOTE: This publication is on clearance and will soon be out of print.

Table 1
Summary of Alcohol and Other Drug Abuse Curricula for Physicians (continued)